Patient name: Nicolas Cn
Medical Record #: 110
Date of birth: 6/20/00
Date of admission: 7/6/00
Date of discharge: 7/9/00
Private doctor: Sister's clinic
Cc: Dr. Hafezi

Nicolas presented at 15 days of life with a two-day history of fever and =
irritability.  Mother also reported three episodes of emesis.  PO intake =
had otherwise been good, and there was no change in urinary or bowel =
habits.  In the emergency department, the patient was afebrile. A sepsis =
work-up was performed because of the history of fever. A CBC showed WBC =
=3D 16.2 and Platelets =3D 724.  CSF showed three white blood cells, =
four red blood cells, glucose =3D 40, protein =3D 122.  Urinalysis was =
negative.  Serum chemistry was significant for a TCO2 of 16.4 and total =
bilirubin of 6.5 (direct bilirubin of 0.3).  Nicolas was given an IV =
fluid push, started on ampicillin, gentamicin and acyclovir, and =
admitted to V7. A cardiac murmur was also detected on exam.

On the floor, the patient did well, remaining afebrile. A cardiology =
consult was obtained which revealed a normal echocardiogram. All =
cultures including a PCR for herpes were negative at 48 hours and =
antibiotics were discontinued. Patient was discharged home with a =
diagnosis of fever, irritability and functional murmur. Parents were =
asked to follow-up with the private doctor.

Thank you very much for this referral.  A full discharge summary will =
follow from Children's Hospital.  Please do not hesitate to contact us =
with any questions.

Sincerely,

Peter Winkelstein M.D.